Electronic Health Record (EHR)

computerized lifelong record health care record w/ data from all sources
technology that intertwines health info from a variety of sources
every encounter an ind has w/ the health care system is documented (labs, scripts, ER visits, etc...)

Why were chances in technology made?

Medical Errors

-among most common causes of death, occur b/c:
*Lost medical records
*Miscommunicated pt request/messages
*Unreadable info due to poor handwriting
*Mislabeled lab specimens
many of these errors could be overcome if info tech were applied throughout healthcare system.

Personal Health Record (PHR)

Acute Care

most often refers to a hospital, treats pt's w/ urgent problems that cannot be handled in another setting (hospital records keep track of time-limited episodes where dr charts reflect the ongoing health of ind) **Inpatient treatment**

What are the advantages of EHR's?

Will the decision of going completely electronic have a huge impact on pt efficiency?

What is a Total Conversion?

method of converting medical records all at one from paper to electronic, may be costly, but it allows all pt data to be converted at once while office can still service pt's **outsourced to an external company**

What is Incremental Conversion?

gradual change to electronic records. Advantage of this type of change are lower cost and a smoother transition due to less of an impact on the office. Disadvantages are that paper still needs to be used and not all pt data is available. **usually begins w/ pt's w/ scheduled appt***

What is Hybrid Conversion?

using a combination of paper and electron form of data. No matter what form is used dr still need to enter progress notes (most dr choose dictation/transcription process) **some may be outsourced, others in house*

What are clinical templates and what do they allow?

structured form (progress notes) that allows dr's to document pt encounters into an EHR, once it is entered it must be INTEROPERABLE: must be able to exchange info and use it in a meaningful way, therefore clinical standards are important to the details of pt info

Clinical Standards

Types of Clinical Standards

-CLINICAL VOCABULARIES- set of common definitions for medical terms, they ease communications by decreasing ambiguity
-SNOMED-CT- clinical vocabulary designed to encompass all terms used in medicine
-LOINC- terms and codes used for electronic exchange of lab results and clinical observations
-UMLS- thesaurus database of medical terms

ICD-10-PCS

CPT

Current Procedural Terminology- list of descriptive terms and identifying codes for reporting medical services and procedures performed by health care professionals in outpatient setting, developed and maintained by American Medical Association (AMA)

HCPCS

Healthcare Common Procedure Coding System- level II, national codes, contains codes for products, supplies, and certain services not included in CPT. Codes are maintained by Center for Medicare and Medicaid Services (CMS)

Nonverbal Communication

Respect

essential part in the process of communication w/ coworkers, pt's & visitors. Following steps to create a comfortable environment:
*refrain from making jokes or negative remarks that demean the abilities, skills or aspects of coworkers
*be patient & respectful when speaking w/ a caller that does not speak English clearly

What clinical information must be included in the patients chart?

-Vital Signs: measurement of the pt's temp, respirations, pulse and blood pressure
-Chief Complaint: A verbal account made by the pt's describing their problem
-Progress Notes: Documentation of the care delivered to a pt along w/ necessary info regarding their diagnosis and treatment
-Past Medical History: Info regarding the pt's past medical problems, conditions or surgeries
-Family History: Info regarding the medical problems of pt's family
-Social History: Info regarding the pt lifestyle such as smoking, drinking, habits, relationship status, & sexual history
-Allergies- List of the pt's allergies as well as their reactions to each one
-Medication List: Info regarding the dosage & freq of the pt's meds
-HPI (History of Present Illness): compilation of info regarding all aspects of pt's present illness
-ROS (Review of Systems): inventory of body systems in which the pt reports signs or symptoms he or she is currently having or has had in the past
-Diagnosis & Assessment: dr's conclusion regarding the cause of the pt's problem
-Plan & Treatment: dr's recommended plan of action to cure or manage the pt's condition

Patient Flow

Clinical Tools

EHR's allow dr's the ability to access research, detail natioanl treatment and makes pt's w/ chronic diseases easier to manage. EHR's also allow dr's to: Order test Order Meds *Send scripts directly to pharmacy. It also has features that check for medication contraindications and errors

EHR'S and Billing and Coding

Most EHR's have features that automate the coding process, though each EHR these features may vary, these codes are checked for accuracy by a coding specialist. COMPUTER ASSISTED CODING works in a variety of ways, some may assign codes based on keywords, other analyze words/phrases and sentences. The integration of automated coding w/ the billing system facilitates claims processing

Must every service submitted for payment be documented in the pt's medical record?

Decision Support Tools

make the latest clinical info available at the point of care
some of the most common features inc: access to clinical info while making a diagnosis, ID'ing pt's @ risk for a specific disease and adherence to guidelines if pt monitoring is necessary. Clinical Tools will also do the following: Screen for illness and disease Identify at risk pt's *Aid w/ disease management

What are clinical guidelines?

Medication Errors

errors in prescribing medicine harm almost one million americans per yr. These errors range from prescribing a drug that interacts w/ drugs that the pt is already taking to dispensing the wrong med due to poor handwritting

E-Prescribing

the ability to e-prescribe is a feature of most EHR programs. One of the main advantages is it's ability to quickly perform safety checks, EHR programs will send alerts for potential prescription problems.

EHR in the Hospital

EHR in a hosp is extremely important to pt care. EHR compiles data from multiple clinical systems and provides a single source of info about that particular pt. EHR will also capture and store info about the pt care. It will assist in managing transactions such as: medicine prescribed, test ordered/results, and ultimately improving the quality of pt care.

The 5 rights to medication administration (eMars)

Order Sets

pre-defined groupings of standard orders for a condition, disease or procedure. These order sets make it easier to deliver quality care by eliminating errors and providing easy access to clinical content.

Adverse Drug Event (ADE)

Medication reconciliation

Personal Health Record (PHR)

the compilation of the various componets of a pt's lifelong medical history into an electronic format, may incl personal history, allergies, past immunizations, previous surgeries and much more. While the pt is usually responsible for the creation and maintenance of their personal record, they have the option to share the info w/ their provider. Educate pt's as well as those involved in their healthcare. Make it easier to monitor their health, record observations, and follow plan recommendations

Does the PHR replace the legal records of any of the patients providers?

Benefits of the Personal Health Record

PHR is proof that the medical system is evolving to fit the needs of the fast-paced, constantly changing lifestyle that many of us are accustomed to. As consumer begin to make use of this resource, bulky, time consuming forms will be a thing of the past.

What are a few of the "perks" of the PHR?

-elimination of errors made by pt filling out forms that request info the pt might not have access to
-allows pt w/ health concerns to travel w/ less worry since their records can be accessed from any location
-ensures the safety of health record located in healthcare facilities in the event of a natural disaster

Computer-based, stand alone PHR

Ind gain access their PHR using a software program that has been downloaded or installed onto their computer. Info from this type of health record is transferred to a portable memory device in order for it to be accessed from a diff location

Internet based, tethered PHR

Ind are granted access to this PHR through an outside organization, such as ins co or pt's dr. Unlike other versions of PHR, users of an internet based PHR may have limited editing capabilities. Ownership of this version of the PHR is maintained by the organization that provides access to the user. Not a true PHR. May include Patient Portals

Internet based, untethered PHR

Internet based, networked and interoperable

a networked PHR allows the transfer of info of the pt's dr and of other health care org such as ins co and pharmacies. A networked PHR is continually updated. One big disadvantage of this PHR is that it does not ensure complete privacy and security.

Does the release of any info require authorization?

General Authorization

Specific Authorization

Rights of Individuals

Notice of Privacy Practices describes the CE practices regarding the use and disclosure PHI. The CE must document when the pt receives such notice. Ind also have right to access and inspect a copy of their PHI, request an amendment of record, request restrictions on uses and disclosures of PHI and file a compliant about a violation w/ the Office of Civil Rights

Systematized Nomenclature of Medicine Clinical Terms (SMOMED-CT)

Unified Medical Language System (UMLS)

How is medical terminology broken down?

Into word roots, prefixes,, suffixes and combining vowels and forms. Word roots, or base words, are the foundation of the healthcare term. A SUFFIX is a word ending, a PREFIX is a word beginning and a combining vowel (usually an o) links the root to the suffix or to another root. the combining form is word root plus the appropriate combining vowel

Full ROM

Synovial Joints

free moving joints are surrounded by joint capsules, many of the synovial joints have BURSAE-sacs of fluid that are located between the bones of the joint and the tendons that hold the muscles in place

Eversion

Inversion

Protraction

Retraction

Rotation

Fractures

broken bone, most occur as a result of trauma, however some diseases like cancer or osteoporosis can also cause spontaneous fractures. Fractures can be classified as simple or compound. Simple fractures do not rupture the skin, as compound fractures split open the skin allowing for an infection to occur